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Specific Response Registry Form

  1. Select One:

  2. REGISTRANT INFORMATION

    Please complete this section for the subject of this registry. Note: A separate registration form must be submitted for each person to be registered.

  3. Identifying Marks:

  4. ID Wear (Check all that apply)

  5. Does the Registrant have a primary Caregiver?

  6. Does the Registrant live alone?

  7. Are there any animals in the home?

  8. Is there a service animal in your home?

  9. MEDICAL INFORMATION / IMPAIRMENTS

  10. Check all that apply:

  11. Mobility:

  12. Hearing:

  13. Speech:

  14. Vision:

  15. Mental Health:

  16. Does the registrant tend to wander off?

  17. Language:

  18. You may upload a photograph of the registrant if you believe it would assist the responding personnel.

  19. EMERGENCY CONTACT

  20. IMPORTANT: Please review the following before submitting this form:*

    Responding to this form is strictly voluntary. By completing and submitting this form, I acknowledge that the information provided herein is accurate and was submitted voluntarily. I understand that the information on this form will be added to the Town’s dispatch systems and may be distributed to emergency responders in order to better care for me and my family members. I understand that all information provided may be a public record subject to disclosure to the public. I also understand and acknowledge that the Town’s dispatch center is not a “covered entity” under the Health Insurance Portability and Accountability Act (“HIPPA”) and I have no rights with respect to the possession, use or disclosure of this information by the Town’s dispatch center under HIPPA. I further understand that providing this information does not entitle me or anyone in my household to preferential treatment, including a more timely response by emergency personnel. I recognize that in the event of an emergency I must dial 911. I acknowledge that I am responsible for the accuracy of the information provided and for updating the information when it changes or annually. I further understand that this information may be removed from the database and destroyed after one year until I resubmit the information.

  21. Leave This Blank:

  22. This field is not part of the form submission.